Prescribing preferences for reduced-dose direct oral anticoagulation for extended-phase venous thromboembolism treatment

Background: Direct anticoagulants (DOACs), apixaban and rivaroxaban, are used for the treatment of venous thromboembolism (VTE) and have product labeling to dose-reduce for extended-phase secondary prevention of VTE. The objective of this study was to better understand prescribing patterns of DOACs among a broad cohort of clinicians. Methods: In this secondary analysis of a survey deployed to two distinct populations of clinicians, thrombosis specialists and primary care physicians (PCPs), we used descriptive statistics, Fisher's exact test, and regression to explore relationships between respondent demographics and prescribing behaviors. Results: Among 336 respondents, 12 % were pharmacists, 23 % were PCPs, and 65 % were specialists. Most (59 %) practiced in an academic setting, and 18 % practiced outside of North America. When considering provider type, 88 % of pharmacists, 78 % of specialists, and 61 % of PCPs indicated that they dose-reduce DOACs for extended-phase therapy for the secondary prevention of VTE (p-value = 0.002). PCPs were most likely to engage in temporary dose-escalation (p-value < 0.001) when presented with various scenarios of increased risk. Providers who prescribed DOACs in >250 patients were also more likely to dose-reduce (aOR 2.41, 1.24-4.82 95 % CI, p-value = 0.01). Pharmacists overwhelmingly preferred prescribing apixaban, while PCPs and specialists were more balanced between prescribing apixaban and rivaroxaban (p-value < 0.001). Conclusion: Most clinicians elect to dose-reduce DOACs during the extended phase of anticoagulation. Provider type and number of patients correlated with prescribing practices. These findings identify opportunities to advance clinician education surrounding dose-reduction when clinically indicated.